EBP FINAL

2

INTIMATE PARTNER VIOLENCE EDUCATION

Intimate Partner Violence Education for Pregnant and Postpartum Adolescents and Young Adults

2021 DNP Student

B. S. Nursing, University of Missouri-St. Louis, 2016

A Dissertation Submitted to The Graduate School at the University of Missouri-St. Louis in partial fulfillment of the requirements for the degree

Doctor of Nursing Practice

December 2021

Advisory Committee

Laura Kuensting, DNP.

Chairperson

Kimberly Werner, Ph.D.

Kacie Smart, M. A.

Copyright, Tatiana O. Filajdic, 2021

Intimate Partner Violence Education for Pregnant and Postpartum Adolescents and

Young Adults

Intimate Partner Violence (IPV) is a public health concern affecting millions of people in the United States each year and may involve acts of physical violence, sexual violence, stalking and/or psychological aggression. Risk factors for IPV include adolescence and young adulthood, low income, low education level, unemployment, and history of exposure to violence, child abuse, neglect and/or sexual violence (Niolon et al., 2017). There is a relationship between health and exposure to IPV as adolescent IPV may yield serious consequences such as poor health, risky sexual behavior, unplanned pregnancy, substance abuse, unhealthy weight control, sexually transmitted disease, post-traumatic stress disorder, suicide and/or homicide (Basile et al., 2016). IPV may occur more frequently in high-poverty, low-economic opportunity communities where economic inequality exists, which may contribute to higher adolescent pregnancy rates within those communities (Northridge, Silver, Talib & Coupey, 2017). Adjustment to life after IPV exposure can be difficult, impacting personal relationships, ability to attend work or school, and an overall sense of normalcy.

The prevalence of IPV in the United States is different for women and men, but both genders experience IPV. The National Intimate Partner and Sexual Violence Survey (NISVS) found one-in-four adult women and one-in-seven adult men in the United States have been victims of physical IPV in their lifetime (Niolon et al., 2017). Niolon et al (2017) also reported, 16% of women and 7% of men have experienced sexual violence, and 10% of women and 2% of men have reported being stalked. Additionally, 47% of women and men reported experiencing psychological aggression by an intimate partner (Niolon et al., 2017). The NISVS also found IPV often originates during adolescence due to the commencement of dating and relationship formation. Approximately 8.5 million women and over 4 million men in the United States reported their first experience of physical violence, rape or stalking from an intimate partner before the age of 18-years (Niolon et al., 2017). According to the Department of Health and Human Services [HHS] (2017), IPV affects 1.5 million adolescents annually with one-in-three adolescents as victims of IPV. Of these, only 33% of adolescents report the offense (HHS, 2017). Furthermore, a correlation may exist between a history of physical and/or sexual abuse, repeat exposure to abuse, and adolescent pregnancy.

Understanding the importance for early identification of IPV is essential. Exner-Cortens, Eckenrode, Bunge and Rothman (2016), found adult IPV is directly associated with adolescent IPV and those reporting adolescent dating violence were more likely to experience IPV later in life compared to those with no prior victimization. They concluded adolescent dating violence may become chronic and is an important risk factor for IPV in adulthood (Exner-Cortens et al., 2016). Hence, the recommended primary and secondary prevention strategies to stop the cycle of violence.

In a residential shelter for single women aged 16-22 years who are pregnant or immediate postpartum, there was an opportunity for improvement in IPV education. The Institute for Healthcare Improvements Model for Change served as the framework for this quality improvement project with a Plan Do Study Act (PDSA) cycle. The purpose of this project was to provide IPV education and resources for those who are at high risk of IPV. The aim of this project was for all residents to attend and engage in at least one educational session about IPV within a three-month period. The primary outcome measure was participant responses to interactive questions throughout the educational sessions. The secondary outcome measure of interest was attendance at an IPV education session. The question for study was: In pregnant and postpartum females aged 16-22 years living in a residential shelter, how does IPV education with an interactive component impact awareness of healthy and unhealthy relationships?

Review of Literature

To conduct the literature search, PubMed, Medline (EBSCO) and the Cochrane Library were utilized. Key search terms and phrases included adolescents, intimate partner violence, screening, resources, postpartum and pregnancy, with use of the Boolean operators AND and OR. Initially, 3,921 results were generated based on the key search terms and phrases. Inclusion criteria were studies from 2015 to 2020, published in the English language, and two age filters were applied including: 13-18 years and 19-24 years. Publications selected were all from the past five-years to ensure the most up to date information. Exclusion criteria were those publications with a male or older adult IPV focus, or not published in English. After inclusion and exclusion criteria were applied, 71 publications were generated and ultimately 12 publications were selected for this review of literature.

Assessment and screening for adolescent IPV has been identified as a need in the United States. The use of a screening instrument may be the only opportunity for some adolescent females and young women to disclose their abuse. Those who are identified to be at risk for IPV may prompt conversation and promote referral to resources. Niolon et al. (2017) recommended education about and awareness of resources available to prevent depression, trauma, stress, and anxiety related to IPV.

Despite the availability of validated IPV screening instruments, they appear to be underutilized in primary care practices. Sharpless, Nguyen, Singh, and Lin (2018), demonstrated the need for an improved IPV screening process in a primary care setting. Of 500 medical records audited, only 111 (22%) patients had been screened for IPV (Sharpless et al., 2018). Interestingly, the least number of screenings were completed on those 18-29 years, which is problematic when IPV is most prevalent in those ages. Sharpless et al. (2018) concluded females of child bearing age should be screened for IPV at each visit, including adolescent well-visits. In low-income, urban, pregnant adolescents, Thomas et al. (2019) found 38% reported experiencing IPV in their third trimester when screened. Higher rates of depression and anxiety were also found in those who screened positive for IPV when compared to those who were not likely to be experiencing IPV (Thomas et al., 2019). Thomas et al. (2019) recommended community-based prevention efforts were equally important as screening, especially for vulnerable populations such as pregnant adolescents. Thus, primary prevention strategies (for those who have not yet experienced IPV) and secondary prevention strategies (for those who have experienced at least one episode of IPV) need to be considered in early adolescence.

The Healthy Relationships Quiz was created by the HHS as a free service for adolescents and is the first screening instrument specifically for this age group. There are 26 yes/no questions, which are scored and calculated for IPV risk (HHS, 2017). The Healthy Relationships Quiz was recently studied for its use as a screening instrument upon intake in an urban, midwestern, residential shelter for pregnant and postpartum adolescent and young females. Of the 19 intake records reviewed, 18 reflected a score indicative of IPV risk, however, there were no scores indicative of immediate danger (Myers, 2020). This finding was consistent with Thomas et al. (2019) finding adolescents of childbearing age were at increased risk for IPV.

Education has been identified as a need in both primary and secondary IPV prevention efforts and several programs have been investigated. De La Rue, Polanin, Espelage and Pigott (2017), discussed the Safe Dates Program, a school-based primary prevention intervention teaching adolescents to distinguish safe, healthy relationships from unhealthy relationships. The aim was to change gender role, sexual behavior and teen dating violence norms and improve conflict management skills (De La Rue et al., 2017). Miller, Jones and McCauley (2019), investigated the Green Dot bystander behavior program, which has shown reductions in sexual violence, sexual harassment, stalking and dating violence. The Safe Dates Program and the Green Dot bystander behavior program are the two most common primary prevention programs.

Another educational program is Project Date SMART, which has a secondary prevention focus. This program utilizes cognitive behavioral therapy (CBT) to teach coping skills to females with a history of IPV exposure, which demonstrated a reduction in victimization and depression (Rizzo et al., 2018). Reidy, Holland, Cortina, Ball and Rosenbluth (2017) examined the efficacy of Expect Respect Support Groups (ERSG), a school-based violence prevention program for those with a history of exposure to violence in their home, school or community. ERSG session attendance was correlated with declines in teen dating violence (TDV) and aggression due to education which allowed for increased awareness and reporting of TDV (Reidy et al., 2017).

While other programs have a school-based education focus, online education is an alternative method. Hegarty et al. (2019) investigated I-DECIDE, an online healthy relationship instrument and safety decision aid for women experiencing IPV. A two-group randomized control trial was utilized to determine its efficacy. While there was no difference in depression symptoms between the two groups, the intervention group found the modules supportive and motivating (Hegarty et al., 2019). This study had a focus on adult women, therefore further research is needed to determine the significance of the I-DECIDE instrument in adolescent females with a history of IPV exposure.

Insufficient funding is a problem across implementation of programming in schools nationwide. Educational programs are of particular importance as they help prevent IPV in adolescence, which continues into adulthood. Education can also help prevent recurrence in those with a history of exposure to IPV as they are at risk for subsequent violence. Through this review of literature, a need for increased focus on primary and secondary IPV prevention was highlighted. Such prevention should start as early as elementary and middle school years as 51% of 7th graders and 72% of 8th and 9th graders reported dating (HHS, 2017). Primary prevention assists in decreasing occurrence of IPV in adolescence and adulthood, while secondary prevention aids in prevention of trauma and revictimization in those with a history of IPV exposure.

There have been potential interventions identified for those at risk for and those with a history of IPV exposure. A gap in the literature exists for IPV in pregnancy, however, reproductive coercion has been recognized as a concern for this population. Reproductive coercion is a form of IPV involving interference with contraceptive methods, such as discarding birth control pills, condom manipulation, and/or pregnancy pressure and may contribute to health disparities in adolescence such as high unintended pregnancy and sexually transmitted disease rates (Northridge et al., 2017). Of 149 sexually active adolescent females aged 14-17 years surveyed, reproductive coercion was reported by 29 (19%) (Northridge et al., 2017). According to the NISVS (2017), at least 9% of women have experienced reproductive coercion, but few studies explore this concept in adolescent and young adult females.

Miller et al. (2017), utilized Addressing Reproductive Coercion in Health Settings (ARCHES), a prevention education and counseling intervention to help guide discussion about abuse and reproductive coercion. ARCHES provides reproductive coercion resources to females whether they choose to disclose information about their history of IPV or not (Miller et al., 2017). Miller et al. (2017) found an increase in self-efficacy to engage in harm-reducing behaviors and use of resources in adolescent females and young women after participating in the program.

Another program, Domestic and Other Violence Emergencies (DOVE) intervention is a home-visit empowerment program where women receive three in home visits during pregnancy and three visits postpartum. Visits consist of routine prenatal care and empowerment interventions focusing on education and safety planning. The DOVE intervention was shown to significantly decrease IPV over time using the Conflict Tactics Scale (Chisholm, Bullock & Ferguson, 2017). Chisholm et al. (2017) identified the concept of psychological first aid as the need to help those at risk identify and understand abuse. The importance of screening women for past and current abuse is emphasized and supportive care should be provided to decrease violence and its subsequent complications.

Gender may influence the type of abuse experienced and perpetrated by an individual. Reidy et al. (2016), found females were more likely engage in psychological and physical perpetration, while males were more likely to engage in sexual and physical IPV, which demonstrated the need to modify IPV prevention efforts based on gender. Niolon et al. (2017), found women-focused interventions helpful in improving both physical and emotional health and safety-promoting behaviors in females at high risk for IPV. Counseling was found beneficial in decreasing IPV, decreasing involvement in unsafe relationships and helpful in yielding positive birth outcomes (Niolon et al., 2017). Tailoring IPV interventions to meet an individuals’ needs is important in preventing long term consequences.

The Institute for Healthcare Improvements Model for Change is a common framework used for testing change. Cycles of PDSA enhance continuous systemic improvement and small-scale change (White, Dudley-Brown & Terhaar, 2019). Continuous, systemic improvement is relevant for an ongoing problem such as IPV where progress will continue beyond this cycle. PDSA cycles support ongoing adjustment and refinement, allowing for continuous improvement in hopes to break the cycle of IPV.

In summary, IPV in postpartum adolescent females and young women is a public health concern, however it is preventable with proper awareness, screening, education and resources. Primary prevention through education and resources should be implemented in early adolescence to best prevent IPV from first occurring. Secondary prevention efforts help decrease revictimization and trauma in those with a history of IPV. Screening should be utilized as recommended to recognize those at risk for IPV and to support those in need of education and resources. Due to low reporting of abuse from adolescents, concern arises about the level of understanding of IPV, further signifying the need for screening and education. There are gaps in the literature on adolescent IPV and IPV in pregnancy despite these populations being at high risk for IPV. Understanding how adolescents perceive abuse and the language they use to define it is essential. Having such information will help guide the development of education best tailored to the needs of this population. Pregnant and postpartum adolescent females should be screened for IPV and provided with education and resources to help them identify healthy relationships and prevent IPV from occurring or reoccurring.

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